Wednesday, March 11, 2009

1. Is type 1 diabetes genetic?
2. Is type 2 diabetes genetic?
3. What are the symptoms of type 1 diabetes?
4. What are the symptoms of type 2 diabetes?
5. What tests detect diabetes?
6. How often should I see my doctor if I have diabetes?
7. When should I get emergency care if I have diabetes?
8. How are blood sugar levels tested?
9. What is a "glycosylated hemoglobin" or "hemoglobin A1c" test?
10. How often should the hemoglobin A1c test be performed?
11. How often should I have my eyes checked if I have diabetes?
12. Why should I should I have my urine checked if I have diabetes?
13. Why should I have the sensation in my feet checked if I have diabetes?
14. How often should I be screened for heart disease if I have diabetes?

Diabetes Detection
Is type 1 diabetes genetic?

Most of the time when I see someone with type 1 diabetes, I don't usually think they're going to have a family member with it. If they do, it's going to be something very distant. So, we know that there is a genetic component to type 1 diabetes, but there is also an environmental component. Something happens that we don't understand really; some trigger, something toxic, something chemical, or something viral, that creates the diabetes and creates the destruction of the insulin creating cells in the pancreas. I do have, rarely, families where there's two siblings with type 1, but it's not that common.
Is type 2 diabetes genetic?

With type 2 diabetes I always say, who else in your family has this, because it is so genetic. And even though there's this huge environmental component, so that the genes that cause type 2 diabetes if you live in rural Mexico and you're out in the field working, you're not going to have diabetes. But if you and your sister move up to LA, you're going to end up getting diabetes because suddenly you're no longer working in the fields, you're much more sedentary and you're eating a lot more food and in particular a lot more junk food. So type 2 diabetes, the way I look at it, is almost always found in families. The corollary to that is: if you have type 2 diabetes make sure you watch out for your kids and your siblings and even your parents, because I see it up and down in families. I'll see somebody who gets it in their forties who will then find out that their mother has it and who will look at their kids and try to figure out how to keep their kids from getting it; so this is a family disease.
What are the symptoms of type 1 diabetes?

Type 1 diabetes is often found in people where they become really thirsty. It's not generally a subtle thing: their blood sugar levels become very high, say 300 or 400, and considering normal is about 100, that's very high. They'll get thirsty, they'll urinate a lot, they'll feel tired, and they'll lose weight; they're kind of the classic symptoms of someone getting type 1 diabetes. Now, when kids get type 1 diabetes, they tend to seem really sick. They get a lot of symptoms; they get thirst, they get dehydration. The parents will really notice there's something wrong with their child. When people, though, get type 1 diabetes as an adult, they actually might not have symptoms. They may not really have symptoms at all until their doctor picks it up on a routine blood test. So, at least from my own experience, adults getting type 1 diabetes may end up not having symptoms; it would end up as being something they found out from their doctor. So, don't assume that a lack of symptoms means you don't have type 1 diabetes. You could be getting it and just not know it yet.
What are the symptoms of type 2 diabetes?

In the vast majority of cases, people with type 2 diabetes have no symptoms and that's a big problem, because just because they don't have symptoms, doesn't mean there is not harm going on. In fact, all of the time that they're having high blood sugar levels and not knowing it, they're developing complications of diabetes. So that it's very important if someone's at risk, if they have a family history of diabetes, if they're overweight, particularly in the center. If they have high blood pressure. If they have abnormal cholesterol levels. Those people need to go every single year and get a fasting blood sugar test at their doctors, to be sure that they don't have it.In the United States we estimate that most people have diabetes for 5 to 7 years before it's diagnosed. So that's why people need to know to go in. Now, that being said, there are things that people might notice. As I said, gaining weight in your center, really good sign that you're at risk for diabetes. Another thing is a syndrome called Polycystic Ovarian Syndrome that women get where they have irregular menstrual cycles. They may have increased facial hair, problems with fertility. Those people are actually at high risk for getting diabetes. A woman with high blood sugar levels may complain of frequent vaginal infections. People may complain of wounds not healing quite as well. They might be a little more tired. Their eyes might be a little more blurry and even people with type 2 diabetes can get that excessive urination, thirst and weight loss. But that's very, very few. Most people don't know that they're sick until it's picked up in a doctor's office.
What tests detect diabetes?

The good news is that it's really easy to detect diabetes, because it's a disorder of blood sugar. We know that a normal blood sugar is 100 or less. So, if you go in to see your doctor, and you haven't eaten anything overnight, you have, what we call, fasted for twelve hours (you can have water). They check your blood sugar, and if it's between 100 and 125, it means you have pre-diabetes, or you're someone who's on the way to get diabetes. If your blood sugar is 126 or more, it means you have diabetes. Now, in medicine, we never do anything once, so we say that if your number's abnormal, you need to go back in and have it rechecked so that we can make sure that that's truly the diagnosis. It's more important to me, though, that people know that they're at risk. Say your blood sugar's 112 this year and then it becomes 126 next year. What's happening is that you're just gradually getting worse and worse, and what you want to do as an individual is to change whatever you can change, or take medication, so that the disease doesn't get worse.
How often should I see my doctor if I have diabetes?

When people have diabetes, they need not only to go to their healthcare provider more frequently, they actually need to really take charge of their healthcare because the beauty about diabetes is it's numeric. So we tell you what your blood sugars needs to be and we also tell you what your average blood sugar over three months should be and there's a test called the Hemoglobin A1c that tells us what your blood sugar is. It tells you what your blood sugar is. You also need to manage your cholesterol levels, your good and bad cholesterol levels and your blood pressure. Most people worldwide don't get close to the kind of medical care they should for their diabetes and it's in part because diabetes doesn't hurt. So you go to your doctor because your back hurts and your doctor has ten minutes to spend with you. At the end of that, they are not going to have talked about your blood pressure and your blood sugar and all these other things you need to do to live long and healthy with diabetes. So what is recommended is that routinely people go every three months to have their diabetes checked out. And this really needs to be a visit that is not an acute visit for something else. This needs to be, you know, "Hey, how's my blood sugar? How's my blood pressure?" And I really recommend that people keep track of it because there are such clear targets and guidelines. You really need to know what was your blood pressure last month? What is it three months from now? And if it's not normal, you need to ask, "How can I get it better"? Because people who take a proactive approach to their diabetes do beautifully.
When should I get emergency care if I have diabetes?

A really serious problem that people with diabetes have is that they end up getting amputations of their feet and legs. In fact it's the #1 reason for amputations in the United States, separate, of course, from motor vehicle accidents. It turns out the most reasons people need amputations is because they get a little tiny cut or sore in their foot and they have what we call "diabetic neuropathy" which means they can't feel that. Not everybody with diabetes has neuropathy, but those who have nerve damage can't feel that little cut or sore and then it will spread and it can get bigger and bigger and then go to the bone and then they'll end up losing their foot. However, if people with diabetes check their feet every day and call the doctor if they see anything abnormal, they can prevent anything bad from happening. There are many other reasons that people with diabetes can go to the hospital or the emergency room. Sometimes it's because they run out of their medication. Sometimes it's because they didn't give enough insulin because they were infected and their blood sugars went up real high. If someone with diabetes on insulin is vomiting and can't keep down food, they don't have any sugar to feed the insulin with and they have to go to the hospital. Low blood sugar reactions can also require someone to go to the hospital. A low blood sugar reaction means that the blood sugar has fallen so low that a person can fall into a coma. Now, the good news about that is that if people with diabetes check their blood sugar levels at home, they can often prevent severe low blood sugar reactions, and there's also a shot called "glucagon" that people can have at home and that a family member could give them to just wake them up. The final thing about low blood sugar reactions is that everybody with diabetes on insulin should have a medical alert that they wear on their body somewhere so that if some bad reaction happens and you're out on the street, people will know why you're having that reaction. So, there are a whole host of things that can happen with diabetes, but the vast majority can be prevented if people know how to prepare for them and then what to do, and finally if they have access to health care when there's an early warning that something's going on.
How are blood sugar levels tested?

What's really nice about diabetes is that you can watch over your disease yourself at home. And we have these blood glucose monitoring devices now, which there are probably, I don't know, 2, 3, 5, lots and lots of different meters. It doesn't matter necessarily so much which one you have, but you need to have one that you understand how to use: A), and B): in many cases that your insurance pays for. But you want to be able to monitor your blood sugar so you know what your sugar level is. And so these machines require that you poke your finger with a lancing device, and the lancing device you just - it's like a little pin prick. And I might add this is actually slightly more painful than giving insulin shots. This is part of diabetes that a lot of people don't like, but it gives very useful information. But you poke your finger and then there's a machine that has a little strip in it. You touch that strip to the drop of blood, and within a few seconds it tells you what your blood sugar level is. And I find these invaluable in terms of blood sugar testing. Now the problem with this is that, say you test your blood sugar four times a day before each time you eat, so you can figure out how much insulin to give, or maybe after you eat, so you can figure out what your blood sugar did in response to a meal. That still leaves lots of time when you have no idea what your blood sugar is, and it can be going up and down or whatever in between. So we now have ways to monitor blood sugar levels continuously by little devices that you attach on to your skin that talk to a device like a pager and tell you what your blood sugar is all the time. And those devices are just new, but they're really fascinating and really helpful in managing people who take insulin injections.
What is a "glycosylated hemoglobin" or "hemoglobin A1c" test?

A "glycosylated hemoglobin" level or “hemoglobin A1c” is a test that measures your average blood sugar for the past 3 months. And it's incredibly helpful because in any given day, someone with diabetes has a blood sugar that goes up and down and up and down again, and what you want to know is really the average blood sugar for the past 3 months. I know that if your hemoglobin A1c is less than 7, your risk of complications, of going blind or going on dialysis is much less. Now all of us have glucose in our blood, so all of us have a hemoglobin A1c level that is somewhere between 4 to 6. So 4 to 6 is normal. But more and more glucose will attach on to your cells as your glucose level goes higher, so the hemoglobin A1c, which is how much glucose is attached to your red blood cells, increases as the average level of sugar in your blood increases. It's a very important test to have checked every 3 to 6 months: every 3 months if you're on insulin, every 6 months if you're on pills, and your blood sugars are pretty stable. But you need to know that number and really be invested in that number. My patients cheer and celebrate when their A1c levels get down below 7 and are really where they want them. That's a great number to know and really vital to managing diabetes.
How often should the hemoglobin A1c test be performed?

The haemoglobin A1c test is a test of the average blood sugar level over about 3 months, and that 3 months is actually the life span of a red blood cell. That's how long we're testing. It's basically how much glucose is attached to red blood cells. So, if you're on insulin, or your diabetes is changing, we recommend that you have a haemoglobin A1c test every 3 months. If someone is on pills and their diabetes is really stable, then they probably should only do the haemoglobin A1c test every 6 months. However, I really recommend every 3 months for most people with diabetes to have a haemoglobin A1c test. A lot of us, if we say we are going to do something every 3 months, end up doing it every 6 months anyway. So, I think it's a very important number and one that people really need to be aware of and follow closely in monitoring their diabetes.
How often should I have my eyes checked if I have diabetes?

People with diabetes can get what's called "diabetic retinopathy" which is damage to the back of the eyes due to high blood sugar levels. Diabetic retinopathy is the leading cause of blindness in adults in the United States, so it's a very serious problem. A lot of my patients say to me, "Why do I need to get my eyes checked, my vision is fine?" The point is that your vision is not necessarily different and yet your eyes can be damaged and damaged and damaged and you won't know it until you go blind, or you bleed into the back of your eyes, or something horrible happens. So, everybody with diabetes should go every year to the eye doctor and get a dilated eye exam, which means they put drops in your eyes to make your pupils dilate and they then look in the back of your eyes very carefully to make sure there's nothing there. There are some people who are under very good control. Their haemoglobin A1C or average blood sugar test is in the normal range and if they don't have any changes in the back of their eye the eye doctor may say come back in two years. However, as a rule of thumb, I say go every year just to be sure that there's nothing there, because if there is something there they can treat it with laser therapy and things are fine.
Why should I should I have my urine checked if I have diabetes?

Diabetes is the leading cause of kidney failure in the United States, but it's a preventable problem, like most of the problems associated with diabetes. And one of the important things about preventing diabetic kidney damage is knowing that there's any damage. And so there's a very early test called a urine albumin creatinine ratio, it's a very little early test to tell us if there's any leakage of protein at all from the kidneys caused by diabetic kidney damage. It tells us if there's even early damage caused by the diabetes. And if there's early damage caused by the diabetes, we can give certain medications to help prevent that early damage from progressing to kidney failure. So every year, people with diabetes, whether type 1 or type 2, need to get a urine test. It's not a 24-hour urine, it's just a urine sample. And you need to ask the doctor to test for diabetic kidney damage. So it's a slightly special test that's not the routine test done on someone without diabetes, and it's one that many doctors don't do. But it's very important to do yearly to be sure that diabetic kidney damage isn't happening, because we have treatments to help if it develops.
Why should I have the sensation in my feet checked if I have diabetes?

People with diabetes get what's called peripheral neuropathy, which means that they lose sensation in their feet and toes. The reason this is important is because diabetes is the leading cause of non-traumatic amputations in the United States. What happens is that your feet might not feel that you've got a cut or a sore. I've had people come to see me with tacks in their feet because they didn't feel the thumbtacks, because they have no sensation. So, every year your doctor needs to check your feet, and tell you if you do have normal feet. If you have diabetes and you have normal sensations, then you're probably pretty similar to anybody else with normal feet. However, if your doctor checks and you have any damage to your feet, if you have poor circulation in your feet, if you have a loss of sensation, if you have foot deformities: bunions, hammer toes; all of those things can make the feet not quite normal. If you have any abnormality in your feet, then you should be absolutely certain not only to have your doctor check your feet every single time you go to see your health care provider, at least three times, four times a year, but also every single day your should check your feet yourself to see if there are any cuts, sores, or lesions, and then if there are, you need to call your doctor right away.
How often should I be screened for heart disease if I have diabetes?

People with diabetes have many risk factors for heart disease. The major risk factors are high blood pressure and abnormal cholesterol levels. Those abnormal cholesterol levels include in particular a low level of HDL, or "good" cholesterol, and a high triglyceride level. We recommend that people with diabetes have their blood pressure checked every time they come see the doctor, and that really the blood pressure is very well controlled. If someone has heart disesase we probably check their cholesterol level two to three times a year. If someone doesn't have heart disease and has normal cholesterol levels we check their cholesterol levels once a year.We tend to be very aggressive at treating both blood pressure and cholesterol levels in people with diabetes because their risk for heart atack and stroke is so high.

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